Scottish Improvement Skills Workshop 2 Scottish Improvement Skills Full Programme Workshop 2 Participant slides

Housekeeping

Workshop 1 By the end of the workshop, you will have planned a first test of change to carry out in the workplace, taking into account the work context and priorities for improvement, and the needs of stakeholders.

Project work By the time your return for Workshop 2, you will have: reviewed the Three Questions with your team collected data to help you identify your priority for change collected baseline data carried out several tests of change collected qualitative and quantitative data

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Workshop 2 By the end of the workshop, you will have created run charts with your own project data, and practised talking about your data with your team or other stakeholders.

Workshop 2 Content Interpretation of run charts Creating run charts on MSExcel An improvement journey: from testing to implementation Talking about data in run charts

Improvement principles By the end of this session you will be able to: apply Deming’s System of Profound Knowledge to help you understand the complexity in your improvement project.

System of Profound Knowledge Deming 2000

Aim: promote staff wellbeing Aim 1 Driver 2 Driver Change ideas Staff complete safety climate survey Promote the physical, mental and emotional wellbeing of staff. By March 2017: (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. Environment Action planning from survey Lean visual management of cupboards, notice boards etc A workplace that is safe for staff Activity Use and location of hand gel dispensers Staff able to focus as required Schedule regular team huddles Leadership training for team leads People Staff engaged in health and wellbeing practices Offer Bereavement support programme for managers

System of Profound Knowledge Deming 2000

System of Profound Knowledge Which of the 4 components are you finding most challenging in your project right now? Is this reflected in what you’ve included, or in there being gaps? What would you advise the project team to work on?

System of Profound Knowledge Deming 2000

Analysing data: interpretation of run charts By the end of this session you will be able to: Explain the importance of using annotation to help interpret run charts Discuss how the type of median used affects interpretation of signals from run charts and impacts on decision making Explain use of phasing, stratification, and what to do with extreme values on run charts.

Analysing data: Interpretation of run charts Annotation Median Phasing Extreme values Stratification

Aim: promote staff wellbeing Aim 1 Driver 2 Driver Change ideas Offer Bereavement support programme for managers Promote the physical, mental and emotional wellbeing of staff. Within 12 months (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. A workplace that is safe for staff Flyer on staff health and wellbeing programmes Staff education Hold staff health fairs Smoking cessation campaign Staff engaged in health and wellbeing practices Set up walking groups Healthy lifestyle programmes for staff Improve staff diet at work Offer lunchtime yoga Enable cycling to/from work

Annotation Hours lost through sickness absence Median 5.2 Fit Note introduced Goal

Median (1) Women walking 10,000 steps Baseline median Extended median Pedometers issued Challenge announced

Median (2) Women walking 10,000 steps Signal detected here Pedometers issued Challenge announced

Median (1) Women walking 10,000 steps Baseline median Extended median Signal detected here Pedometers issued Challenge announced

Creating a baseline median Use historical data if available Collect new baseline data before introducing a change, if this makes sense in your context If no baseline data is available, create a baseline median using the first 10 data points.

Phasing Women walking 10,000 steps Pedometers issued Challenge announced

Interpretation of run charts Each run chart can be improved to make the data easier to interpret. Possible improvements may relate to: Type of median line used Measure used For each chart, decide what improvements would be most useful, and why. Annotation Design

Extreme values Frequent events Rare events More than half the data falls on the median line More than half the data is at ‘extreme’ values eg 0 or 100 on percentage scale

Extreme values (1) Compliance with hand hygiene

Extreme values (2a): Number of needlestick incidents per month

Extreme values (2b): Number of patients seen between needlestick incidents

Stratification (1): Inpatient requests for MRI

Stratification (1): Inpatient requests for MRI

Stratification (1): Inpatient requests for MRI

Stratification (2) Staff walking 10,000 steps (men and women) Median 35.25 Challenge announced Pedometers issued

Stratification (2) Staff walking 10,000 steps (women) Median 29 Pedometers issued Challenge announced

Stratification (2) Staff walking 10,000 steps (men) Median 41 Pedometers issued Challenge announced

Interpretation of run charts Each run chart can be improved to make the data easier to interpret. Possible improvements may relate to: Type of median line used Measure used For each chart, decide what improvements would be most useful, and why. Annotation Design

Analysing data: Interpretation of run charts: summary Annotation Median Phasing Extreme values Stratification

System of Profound Knowledge Deming 2000

Visual display of data: using Excel to create run charts By the end of this session you will be able to: Create annotated run charts with baseline and extended medians using Excel Create an annotated run chart showing phasing with Excel

A New Healthier Me Aim 1 Driver 2 Driver Change ideas Lose 7 pounds in 3 months Leisure activity Calories in meals Calories in drinks Calories in alcohol Work activity Calories in snacks No alcohol Monday to Thursday Max 1 x juice or soft drink per day Reduce portion size Cook evening meals from scratch Replace biscuits/cakes with fruit Keep to shopping list Get up from desk to talk, instead of phone or email Use stairs not lift Walk to a daily step target Swim at least twice a week Calories in Calories out

Visual display of data Basic run chart Run chart with baseline and extended median Run chart with phasing Run charts with your data Annotations.

Leading change: from testing to implementation By the end of this session you will be able to: Describe typical stages in an improvement journey - testing, implementation and spread Make decisions based on learning from PDSA cycles and data analysis Demonstrate understanding of when to move from testing to implementation Draft an implementation plan.

System of Profound Knowledge Deming 2000

An improvement journey A P S D Identify opportunity for change Plan Test Sustain the change Implement Hold the gains Spread

Test cycles: Act on your learning Abandon the change Modify the change Increase the scope of the change Test the change under different conditions Stop collecting data Implement the change

Three criteria for implementation High degree of belief that a change will result in improvement Small cost of failure The organisation is ready to make the change.

From testing to implementation Cost of failure Current commitment within the organisation None Some Strong Degree of belief that change idea will lead to improvement Low Large Very small scale test Small Small scale test High Large scale test Implement Adapted from: The Improvement Guide p146

Sequential building of knowledge A P S D Implementation cycles Learning and Improvement Wide scale tests Test new conditions Follow up tests Small scale test Very small scale test Develop a change

ICU: Reduce Length of Stay Aim Primary Driver Secondary Driver Change idea Reduce average length of stay in Central General ICU by 20% by March 2015 Assessment and management of sedation and agitation Improved management of delirium Validated sedation tool Appropriate sedation Incidence of acute cognitive dysfunction Structured daily sedation breaks Staff information leaflets Staff training sessions Improve multidisciplimary team communication Assess sedation and agitation using the RASS tool (Richmond Agitation Sedation Scale) Use ear plugs to improve sleep Use Dexmedetomidine as alternative to benzodiazipines Develop and follow guidelines for daily sedation breaks Assess for delirium using CAM-ICU (Confusion Assessment Method for ICU patients) Investigate and correct underlying causes Include delirium as part of safety brief Medical staff and family jointly keep an ICU diary Improved identification of delirium Validated delirium tool Staff education Care bundle initiated within 2 hours of diagnosis Engage with patient/family/carer Mobilise patients earlier and more frequently

PDSA Ramps A P S D A P S D A P S D Education package RASS scoring tool Develop content Restructure content – 2 staff nurses Test with 1 staff nurse Revise wording – 1 nurse Test with all staff Education package A P S D Develop tool Amend tool (colour) & test at 1 bed space Test at 1 bed space Test at 2 bed spaces Amend tool (wording) & test at 1 bed space RASS scoring tool A P S D Develop poster Move poster so not obscured when doors opened Display outside ward Layout of poster more readable Size poster to fit space Poster for families

Building knowledge: your project How could you increase your degree of belief? What different conditions could you test your change under? Which change ideas could you work on at the same time? How could you minimise the cost of failure? How could you better make your department/organisation ready for the change?

Components of Implementation Standardisation eg policies, procedures Documentation eg job descriptions Training Measurement Resourcing eg equipment purchases

Aim: promote staff wellbeing Aim 1 Driver 2 Driver Change ideas Staff complete safety climate survey Promote the physical, mental and emotional wellbeing of staff. By March 2017: (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. Environment Action planning from survey Lean visual management of cupboards, notice boards etc A workplace that is safe for staff Activity Use and location of hand gel dispensers Staff able to focus as required Schedule regular team huddles Leadership training for team leads People Staff engaged in health and wellbeing practices Offer Bereavement support programme for managers

Components of Implementation Standardisation eg policies, procedures Documentation eg job descriptions Training Measurement Resourcing eg equipment purchases

Leading change: from testing to implementation: summary An improvement journey Criteria for implementation PDSA ramps Components of implementation

Communicating improvement stories: A framework for talking about data By the end of this session you will be able to: list key components of an effective improvement story describe 4 steps in talking about data.

System of Profound Knowledge Deming 2000

Communicating improvement stories Stakeholder analysis Planning communications Talking about data Writing reports Sharing success

Communicating improvement stories: key stages Why this project Changes Results Lessons learned Next steps

Talking about data: 4 steps The 4 Ws Horse and Cart Dimensions GEE

Step 1: The 4 Ws Where, Who, What, When Median 41 Pedometers issued Challenge announced

Step 2: Horse and Cart

Step 2: Horse and Cart

Step 2: Horse and Cart Median 41 Pedometers issued Challenge announced

Step 3: Dimensions Horizontal axis Vertical axis Data points Median line

Step 3: Dimensions Median 41 Pedometers issued Challenge announced

Step 4: GEE Generalisation Example Exception Summarise what the chart is saying Point out data that illustrates the generalisation Draw attention to any exceptions

Step 4: GEE Median 41 Pedometers issued Challenge announced

Talking about data: 4 steps The 4 Ws Horse and Cart Dimensions GEE

Talking about data: staff who smoke Support group launched Re-launch Free fruit Buddies

Communicating improvement stories: A framework for talking about data: summary Key stages Why this project Changes Results Lessons learned Next steps 4 Ws Horse and cart Dimensions GEE

Communicating improvement stories: Talking about your data By the end of this session you will have created and an improvement story based on your project data, and talked about it using the four-step framework.

Communications plan Stakeholders Purpose of communication Key messages to be communicated Timing of communication

Prepare to talk about your data Paste your run chart into a Powerpoint slide, and annotate. Create 1 – 2 other slides if necessary. Plan what you are going to say using the report structure: Why this project What changes you tested Results Lesson learned Next steps

Talk about your data Small groups Up to 4 minutes – start by telling your audience who they are ‘Audience’ will note some comments and questions 2 minutes for discussion

Feedback What questions might you have as target audience? What do you like about the way the data is presented? Suggest one way this talk could be improved.

Commmunicating improvement stories: Talking about your data: summary Prepare

Next steps Online evaluation Project charter Action planning, including actions that demonstrate: Working with your team on developing and testing changes Use of run charts to display and analyse your project progress Communications within and outwith the project team

And finally … Workshop 3

References and further resources VProvost Lloyd P & Murray S (2011) The Health Care Data Guide: Learning from Data for Improvement Jossey-Bass Online learning module: Measurement for improvement: Presenting data http://www.qihub.scot.nhs.uk/scormplayer.aspx?pkgurl=%2felearningmodules%2fMeasurement+for+improvement+-+Presenting+data%2f&height=800&width=1010